Provider Demographics
NPI:1891896502
Name:BRIST, RACHEL LEA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:LEA
Last Name:BRIST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:190 SAILSTAR DR NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633
Mailing Address - Country:US
Mailing Address - Phone:218-246-2394
Mailing Address - Fax:218-246-8695
Practice Address - Street 1:190 SAILSTAR DR NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3565
Practice Address - Country:US
Practice Address - Phone:218-246-2394
Practice Address - Fax:218-246-8695
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9688363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG499238960Medicare UPIN